Dire straits

Case number:
154

Dire straits

Author: Jason Barton

This 33 year old Japanese woman was seen for inferior central blurriness OS of 10 days’ duration.

She noted this on waking. Since then the area has grown slightly. She denies problems with colour vision, pain with eye movements, or diplopia. She has mild headache towards the end of the day. She has not had any prior episodes. She denies numbness, tingling, weakness, or problems with bladder control. She has otherwise been very healthy.

Acuity without correction at far is 20/25- od and 20/60-2 os (20/50 with pinhole). Pseudo-isochromatic plates are 14/14 od and os. There is a left relative afferent pupil defect. Humphrey 30-2 perimetry below shows her visual fields. Fundoscopy (undilated) shows normal optic discs ou. Pupils are 3mm od/3.5mm os in light and 5.5mm od/6mm os in dark. Palpebral fissures are 10mm od and os.
Ductions are full. She is orthotropic in all primary and secondary gaze positions. Fixation is steady. Pursuit shows good gain vertically and horizontally, and VOR cancellation is normal. Saccades are normal in accuracy and velocity, horizontally and vertically. There is no nystagmus. There are no other neurologic deficits.

OCT of the retinal nerve fibre layer OS is shown:

She comes with a CT scan of her orbits and sella, with contrast, reported as normal.

She returns a month later, without improvement. Goldmann perimetry is shown.

Question: What is going on? And what would you do next? Send your answer to us! (Jason Barton)